BAIT Form

Reporting Party

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Student Name

ID Number

Questions

Please indicate the primary nature of the behavior causing concern.(Required) This field is required.

Please indicate any secondary nature of the behaviors causing concern. This field is required.

Please provide a brief incident description(Required) This field is required.

Appearance Distress Signs: Please indicate any observed physical/appearance based signs of distress regarding the individual for whom you have concern.

Odor

Unkempt Appearance

Dramatic Change in Weight

Bruising

Burns or cuts

Frequent Injuries

Slurring Words

You must make at least one selection.

Emotional Distress Signs: Please indicate any observed emotional signs of distress regarding the individual for whom you have concern.

Tearfulness/Crying

Extreme Mood Swings

Little or No Affect

Seems to Hearing or Seeing Things

Increased Hostility

Anxiety

You must make at least one selection.

Behavior Distress Signs: Please indicate any observed behavioral signs of distress regarding the individual for whom you have concern.

Often Absent

Worsening Academic Performance

Noncompliance

Verbally Aggressive Toward Others

Physically Aggressive Toward Others

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Reporting Party

Involved Parties

Questions

Supporting Documentation

Submission